9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Evanston, IL
5-star overall rating with 4-star inspections with $52,199 in total fines with 9 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
1300 Oak Avenue, Evanston, IL
(847) 869-1300
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
57
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aliya Healthcare
Operator or chain grouping
Approved since
2004-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 3 health / 1 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.89
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.44
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.68
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.00
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.00
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
2.01
CMS adjusted total nurse staffing hours
Case-mix index
2.04
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
7,235
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9859
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.07
Baseline 40.00% · Performance 38.89% · Measure score 6.07 · Achievement 6.07 · Improvement 0.23
Adjusted total nurse staffing
0
Baseline 2.17 hours · Performance 2 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 91.67% |
95.27%
3.6 pts worse
|
Numerator 33 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 69.57% |
53.69%
15.9 pts better
|
Numerator 16 · Denominator 23 |
| Discharge mobility score | 56.52% |
50.94%
5.6 pts better
|
Numerator 13 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 2 · Denominator 36 · Adjusted rate 5.19% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 12.31% |
8.2%
4.1 pts better
|
Numerator 8 · Denominator 65 |
| Staff flu vaccination coverage | 71.23% |
42%
29.2 pts better
|
Numerator 52 · Denominator 73 |
| Discharge function score | 82.61% |
56.45%
26.2 pts better
|
Numerator 19 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.0
0.4 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.9 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.3
1.4 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 48.6% |
89.6%
41 pts worse
|
93.4%
44.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 55.8% · Q2 55.6% · Q3 40.9% · Q4 42.2% · 4Q avg 48.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.8% |
91.6%
1.8 pts worse
|
95.5%
5.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.3%
0.5 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.2% · Q3 2.3% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 93.5% |
50.3%
43.2 pts worse
|
11.4%
82.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.2% · Q2 84.1% · Q3 100.0% · Q4 100.0% · 4Q avg 93.5% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
6.5%
1.3 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.3% · Q3 6.8% · Q4 6.7% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
18.5%
10.5 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 11.4% · Q3 6.8% · Q4 4.4% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 46.0% |
22.8%
23.2 pts worse
|
16.7%
29.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.0% · Q2 51.6% · Q3 48.4% · Q4 37.8% · 4Q avg 46.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 0.9% |
17.2%
16.3 pts better
|
16.3%
15.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.9% |
15.0%
13.1 pts better
|
14.9%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.4% · Q3 0.0% · Q4 2.6% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.3% |
21.3%
4 pts better
|
19.8%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 10.8% · Q3 12.6% · Q4 28.6% · 4Q avg 17.3% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.2%
0.8 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 3.4% · Q3 0.0% · Q4 5.7% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 34.7% |
68.8%
34.1 pts worse
|
81.7%
47 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 37.5% · Q3 35.1% · Q4 32.7% · 4Q avg 34.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.8% |
14.0%
1.2 pts better
|
12.0%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 14.7% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.1% |
2.3%
2.8 pts worse
|
1.6%
3.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 7.4% · Q4 9.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 24.6% |
63.0%
38.4 pts worse
|
79.7%
55.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 24.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.6% |
26.2%
10.6 pts better
|
23.9%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 17.6% · Expected 27.0% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-27
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-01-27
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-27
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-27
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-03-18
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-27
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-27
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-01-27
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-01-27
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-01-27
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-23
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-02-23
Fire Safety
Use approved construction type or materials.
Corrected 2024-02-23
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-02-23
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-23
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-02-23
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-23
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-23
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-02-23
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-11
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-23
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-23
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-20
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-12-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-28
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-12-20
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-20
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-20
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-03
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-11-21
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-11-21
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-11-21
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-05-08
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-03
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-03
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-30
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-30
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-14
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-27
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-01-27
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-01-27
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-27
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-10
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-17
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-17
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-17
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-17
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-17
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-02-17
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-17
Health
Post nurse staffing information every day.
Corrected 2024-02-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-10
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-19
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-04-14
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-04-10
Penalties and ownership
Fine · fine $52,199
Fine
Payment Denial · denial start 2024-02-03 · 37 days
37 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Security Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Nearby options
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Evanston, IL
4-star overall rating with 4-star inspections with $40,258 in total fines with 4 recent health deficiencies
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